Southport Masonic Lodge #270

(PRINT FULL NAME)_________________________________________respectfully represents that having long entertained a favorable opinion of your ancient Institution and having a belief in God, he is desirous of being admitted a member thereof if found worthy. He was born on the ________ day of ______________, 19______, at ____________________, State of ____________________.

He has resided within the jurisdiction of your Lodge for the pe ri od of ______ years and ________ months next preceding the date of this petititon. He has not been rejected by any other Masonic Lodge within the period of one year. The character of the business in which he is engaged as proprietor or employee is ___________________________________________

Recommended by Brother_______________________who has known petitioner ____ years,

and Brother__________________________________who has known petitioner ____ years.

Name _____________________________________________________

Address ___________________________________________________

__________________________________________________________

Hm Ph(_____)_________________Off Ph(_____)_________________

Age ______ Email __________________________________________

Served in armed forces? _________ Branch? _____________________

Father’s name ______________________________________________

Father’s address ____________________________________________

City, State, Zip _____________________________________________

Is (or was) your father a Mason? _________ Lodge Number __________

Lodge Name ______________________________________________

Lodge address _____________________________________________

City, State, Zip _____________________________________________

Any Brother’s Masons? ______________________________________

If so give their names, addressses, and the names and location of their lodges. _________________________________________________________

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Are you married? __________ If so, date ________________________

Spouse’s full name__________________________________________

Place of marriage ___________________________________________

When and where did you last vote in a national election? ______________

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Address’s of where you lived the past 10 years: ____________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

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List places of employment for the past 10 years: _____________________

__________________________________________________________

__________________________________________________________

Present Occupation?__________________________________________

Name of firm_______________________________________________

Address___________________________________________________

City, State, Zip _____________________________________________

Have you ever been denied membership in, or withdrawn your petition to, or

suspended or expelled from any fraternal organization? _____________

Give particulars _____________________________________________

Give names and phone numbers of three business or professional references

other than those who signed this petition:

____________________________________________________________

____________________________________________________________

__________________________________________________________

Do you have any physical impairment? __________________________

If so describe _______________________________________________

Have you ever been convicted of a criminal offense (minor traffic violations

excluded) in a court of competent jurisdiction? ____________________

If so give particulars: ________________________________________

Presented Date ____/____/____ Referred to the following Committee:

____________________________________________________________

____________________________________________________________

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Signature __________________________________________________

Printed: ________________________________Date ____/____/______

Mentor Name: ______________________________________________

Disposition:

Elected Date ____/____/____ E.A . Date ____/____/____

F.C. Date ____/____/____ M.M. Date ____/____/____